Basic Information
Provider Information | |||||||||
NPI: | 1396721411 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STRUYK | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | PATRICK | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 E PENN SQ | ||||||||
Address2: | THE WANAMAKER BUILDING, 9TH FLOOR | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191073323 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2974259300 | ||||||||
FaxNumber: | 2974259331 | ||||||||
Practice Location | |||||||||
Address1: | 34TH STREET AND CIVIC CENTER BLVD, | ||||||||
Address2: | SUITE 9329 | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191044399 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2155901858 | ||||||||
FaxNumber: | 2155901415 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/20/2005 | ||||||||
LastUpdateDate: | 04/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | A100130 | CA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207LP3000X | MD435192 | PA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
ID | Type | State | Issuer | Description | 190520EJL | 01 | PA | MEDICARE PTAN | OTHER | 1022236700001 | 05 | PA |   | MEDICAID |